Reading of the Week: Alcohol Use, ED Visits & Mortality – the New CMAJ Paper; Also, Dr. Lawrence on Diagnoses and Her Diagnosis (Guardian)

From the Editor:

“He’s here again.”

The staff would roll their eyes. Harold was back. Many of us had encountered him – a person with alcohol use disorder who frequently came to the emergency department of the hospital where I did my internship year. He would usually get a sandwich and a lecture. But what are the outcomes for people like him? And what could be done?

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In the first selection, we consider a new CMAJ paper. Dr. Jennifer Hulme (of the University of Toronto) and her co-authors study outcomes for those presenting to Ontario EDs for alcohol-related reasons. The major finding: “The all-cause 1-year mortality rate was 5.4% overall.” We review the paper and its implications.

In the second selection, we look at a new essay by Dr. Rebecca Lawrence from The Guardian. The UK psychiatrist, who has written about her experiences as a mental health patient, notes the challenges of psychiatric diagnoses. “There are many words in the field of mental illness that have been discarded and are now viewed as stigmatising and inappropriate – words such as ‘cretin’, or ‘lunatic’, or ‘mental’. It’s interesting to consider whether our current crop of acceptable words will end up in that category, and it’s salutary to know that many probably will.”

DG

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Reading of the Week: Vaccines, Vaccine Hesitation & Mental Illness, with Papers from JAMA Psychiatry and NEJM, and More

From the Editor:

It’s here. Less than a year after COVID-19 arrived in North America, two vaccines have been created, approved, and given (at least to some).

In the coming months, as the supply improves, people – including our patients – will have the opportunity to get a vaccine. But what are the challenges? First, some will hesitate. In a recent essay, Dr. Nadia Alam notes that: “Vaccine hesitancy is a significant issue with only 57.5% of Canadians saying they are very likely to be vaccinated for COVID-19.” And special populations will present further challenges – such as those with major mental illness.

This week, we focus on vaccinations with two papers and an article.

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In the first selection, drawing from JAMA Psychiatry, we consider a paper by Dr. Nicola Warren (of the University of Queensland) and her co-authors. They note the challenges of reaching people with serious mental illness – just one in four get a flu vaccine. “It is vital to commence planning and development of appropriate policies to ensure rapid delivery of a COVID-19 vaccine when it becomes available.”

In a New England Journal of Medicine paper, Dr. Joshua A. Barocas (of the Boston University School of Medicine) thinks about the needs of those with substance use disorders. “Officials devising vaccination strategies and allocation plans would be wise to do so from the perspective of the virus, rather than that of stigmatizing personal beliefs.”

How to speak to our patients? In the final selection, we look at a short piece by Dr. Joshua C. Morganstein (of the Uniformed Services University of the Health Sciences).  His advice is very practical, and emphasizes that we should tailor our approach not by diagnosis but by patient interest in the vaccination. He also urges us to be careful in our choice of language: “Health care professionals are trained to use complex medical terminology, though more understandable and down-to-earth language often serves to enhance trust and build rapport.”

DG
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Reading of the Week: The Best of 2020

From the Editor 

It’s a Reading of the Week tradition to begin the new year by reviewing the best of the past one. And so, today, we look back at the selections from the previous 12 months.

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2020 was tough, dominated by the pandemic.

The selections aren’t all about COVID-19, however. Papers shed light on the pandemic, yes, but much research helped further our understanding of mental health, relevant in the world that pre-dated the pandemic, and the world after the pandemic.

Looking over the past year of Readings, I would like to make two observations.

First, about the literature: the overall quality of scholarship remains high. As has been the case year after year, I liked the papers highlighted in this series – but also realize that many more papers could have been picked. Psychiatry continues to grow more sophisticated with each passing year.

Second, about the pandemic: COVID is understood to be a threat to physical health, but also to mental health. As a person with a few grey hairs, I remember SARS well. Mental health wasn’t discussed during that viral outbreak. The public dialogue has changed much in these past 17 years. While I wish more attention were paid to mental health and COVID, there have been national and provincial announcements on the topic, and much media attention too. #Progress

DG

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Reading of the Week: More COVID, More Mental Health Problems? Also, e-Cigarette Use (CJP) and Pappas on Her Olympics & Her Depression (NYT)

From the Editor

Will there be a pandemic after the pandemic? Some have wondered about the mental health consequences of COVID-19 – speculating that, in the future, there will be significant mental health problems. In a recent JAMA paper, Simon et al. argued: “The magnitude of this [mental health] second wave is likely to overwhelm the already frayed mental health system, leading to access problems, particularly for the most vulnerable persons.” (That paper was discussed in a past Reading.)

In the first selection, we consider a new paper from Lancet Psychiatry. Kuan-Yu Pan (of Vrije Universiteit) and co-authors did a survey of people with psychiatric disorders, as well as people without. “We did not find evidence that there was a strong increase in symptoms during the COVID-19 pandemic in those with a higher burden of disorders. In fact, changes in scores from before to during the pandemic indicated increasing symptom levels in people without mental health disorders, whereas changes of symptom levels were minimal or even negative in individuals with the most severe and chronic mental health disorders.” Should we be reassured by the Pan et al. study?

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In the second selection, we consider a research letter from Dr. Scott B. Patten (of the University of Calgary) and his co-authors. Drawing on survey data, they describe the pattern of use of e-cigarettes, noting that they were originally intended for harm reduction. “In 2017, 15.5% of e-cigarette users reported that they had never smoked, suggesting a de novo pattern of substance use. By 2019, this proportion had more than doubled to 36.7%.”

Finally, in the third selection, Olympian Alexi Pappas speaks about her mental health in a New York Times opinion video. The comments are very personal, and touch on her illness and recovery. “After the Olympics, I was diagnosed with severe clinical depression. And it nearly cost me my life. But it doesn’t have to be that way.”

Please note that there will be no Reading for the next two weeks. Enjoy the holidays. And if you are looking for a last-minute gift for, perhaps, Hanukkah or Christmas or a way to thank co-workers after a tough year, consider CAMH’s Pet Therapy Calendar, available for just $15 (with the promotion code). Proceeds go to a good cause: the CAMH Volunteer Resources Pet Therapy Program. The calendar is beautifully done, and features great dogs, including Toulouse (my BFF). Here’s the link: https://store-camh.myshopify.com/products/pvol-cal.

DG

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Reading of the Week: Are Benzodiazepines Misunderstood? Also, Lizotte on Mental Health Support, and The Lancet on Those Doctors Lost to COVID

From the Editor

In a recent conversation with a resident, we discussed benzodiazepines. “I’ve never prescribed one,” he explained.

This class of medications is very much out of fashion. But, after decades of overuse, have we swung to the other extreme, and forgotten an important tool in our pharmacologic toolkit? In the first selection, we consider a British Journal of Psychiatry editorial. Dr. Edward Silberman (of Tufts University School of Medicine) and his co-authors argue that benzodiazepines are underappreciated. The selection ties well into a commentary that recently appeared in The American Journal of Psychiatry. Dr. Jerrold F. Rosenbaum (of Harvard Medical School) writes: “My own son, a first-year resident in psychiatry, looks at me as if I served on the wrong side in the Spanish Civil War when I speak of benzodiazepines.” Is there a clinical takeaway here?

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In the second selection, writer and comedian Andrew Lizotte discusses the challenges of being a patient in our mental health system. He shares some jokes – but, ultimately, notes ongoing stigma and power imbalances. “We see how mental illness is portrayed in the media. We are scared of being shot by police during a ‘routine health check.’ We see the lack of empathy. Then people wonder why we don’t ask for help.”

Finally, with an eye on COVID-19, we look at a short paper in The Lancet about those doctors who have lost their lives in the pandemic. “These lives are also a reminder of the ongoing dedication and service of those who continue to care for patients at a time when COVID-19 cases and deaths are increasing in many countries.”

DG

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Reading of the Week: ECT at 82

From the Editor

If you were ill with depression, would you consider electroconvulsive therapy? What if you had a manic episode?

In April 1938, the first treatment of ECT was administered in Rome. Now, 82 years later, ECT continues to be used. But, as Dr. David Goldbloom (of CAMH) notes: “ECT has the unusual status of being one of the most vilified and validated treatments in all of psychiatry and indeed in all of medicine.” The treatment has fallen out of favour, and is not even offered in certain centres.

But would you consider ECT?

In the first selection, we look at a new paper from Psychiatric Services. Dr. Rebecca E. Barchas, a retired psychiatrist, discusses her experiences with ECT – as a patient, not as a physician. She notes the depths of her depression and the decision to receive ECT, which she didn’t know much about despite many years of practice. “If reading these thoughts can help even one more patient who needs ECT accept it or help one more physician to consider recommending it when appropriate, I will have accomplished my goal of helping to destigmatize ECT.”

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In the second selection, we consider a narrative review from The American Journal of Psychiatry. ECT for patients experiencing manic episodes is used less and less often; in several recent surveys, no patient with mania received ECT. But what’s the evidence? Dr. Alby Elias (of the University of Melbourne) and his co-authors review decades’ worth of literature, from RCTs to retrospective studies, finding the treatment is safe and effective. But is it relevant in an era of pharmacology?

DG

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Reading of the Week: Are Those with Mental Illness at More Risk of COVID? Also, a Podcast on Apps (QT) and Horton on Advocacy & Doctors (Macleans)

From the Editor

Are people with mental illness more likely to contract COVID-19? Are they at greater risk of dying?

With the pandemic in its eighth month, we think we have answers to these questions, but data is lacking. In the first selection, we consider a new paper, just published in World Psychiatry. QuanQiu Wang (of Case Western Reserve) and her co-authors analyzed a nation‐wide database of electronic health records of 61 million American patients, aiming to assess the impact of mental illness. “These findings identify individuals with a recent diagnosis of a mental disorder as being at increased risk for COVID‐19 infection, which is further exacerbated among African Americans and women, and as having a higher frequency of some adverse outcomes of the infection.”

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In the second selection, we consider a new podcast discussing digital tools. I talk with Dr. John Torous (of Harvard University). We discuss apps and mental health. And, yes, he has tips on how to pick apps for your patients and their families.

Finally, in the third selection, we look at a new essay by Dr. Jillian Horton (of the University of Manitoba). Should doctors “stay in their lanes?” She argues against the idea, championing a new activism. “So, to my brothers and sisters in medicine: forget about staying in our lane. This is our call to flood the freeways. We cannot stay parked in neutral. There is no more time.”

Please note: there will be no Reading next week.

DG

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Reading of the Week: Substance Problem, Quality of Care Problem? Also, Interventional Psychiatry (CJP) and an Underused Addiction Treatment (NYT)

From the Editor

In terms of depression treatment, do people with substance use problems get worse care than those without?

The answer should be a resounding no. In the first selection, we consider a new paper, just published in The American Journal of Psychiatry, which suggests otherwise. Lara N. Coughlin  (of the University of Michigan) and her co-authors draw on Veterans Affairs data involving more than 53,000 patients. “In this large national sample, we found that patients with comorbid depression and substance use disorders receive lower quality care than those with depression but without substance use disorders.”

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In the second selection, we consider a Canadian Journal of Psychiatry research letter. Dr. Peter Giacobbe (of the University of Toronto) and his co-authors surveyed senior residents, asking about their familiarity and comfort with first line recommendations for the treatment of depression. Spoiler alert: just one in four felt that they had achieved competency in ECT.

Finally, in the third selection, we look at a new essay by journalist Abby Goodnough. With many Americans (and Canadians) struggling with substance problems, she writes about contingency management – that is, rewarding substance users with cash and prizes for sobriety. The concept has evidence in the literature, but lacks political support. She quotes a patient: “Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me.”

Note: there will be no Reading next week.

DG

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Reading of the Week: Trump on Trump & the Goldwater Rule; Also, Chatbots Reviewed (CJP)

From the Editor

Should psychiatrists comment on the possible mental health problems of President Donald Trump? His niece thinks so.

In our first selection, we consider an essay by Mary L. Trump. In this Washington Post essay, the psychologist discusses the Goldwater Rule, which prevents members of the American Psychiatric Association from commenting on political figures. Trump feels that psychiatrists should speak up. “Adopting a notionally neutral stance in this case doesn’t just create a void where professional expertise should be – it serves to normalize dysfunctional behavior.” We consider the essay and the questions it raises.

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In the other selection, we pick another current topic, but this time we draw from a journal, not a newspaper, considering a new paper from The Canadian Journal of Psychiatry. Aditya Nrusimha Vaidyam (of Harvard University) and his co-authors do a review of chatbots for mental health; that is, “digital tools capable of holding natural language conversations and mimicking human-like behavior in task-oriented dialogue with people” (think Siri or Alexa, but for mental disorders). “This review revealed few, but generally positive, outcomes regarding conversational agents’ diagnostic quality, therapeutic efficacy, or acceptability.”

DG

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Reading of the Week: COVID and a Mental-Health Second Wave; Also, Harry Potter & Suicide Prevention (CJP), and Bennett on Bipolar (Walrus)

From the Editor

There are more COVID-19 cases in the community – and in our hospitals and ICUs. What does it mean for mental health?

This week, we have three selections.

In the first, published in JAMA, Dr. Naomi M. Simon (of the NYU Grossman School of Medicine) and her co-authors write about the pandemic and the implications for mental health. They argue that there will be a second wave of mental health problems. “The magnitude of this second wave is likely to overwhelm the already frayed mental health system, leading to access problems, particularly for the most vulnerable persons.” Are they right – and what’s to be done?

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In the second selection, we look at a research letter from The Canadian Journal of Psychiatry. Paula Conforti (of the University of Toronto) and her co-authors consider a CBT intervention for school-age children to reduce suicidality and increase wellbeing. There’s a twist in the plot: the intervention is based on a Harry Potter novel. “This study found that a teacher-delivered, literature-based CBT skills curriculum was feasible and associated with reduced suicidality (ideation and behavior) in middle school-aged youth.”

Finally, in our third selection, we consider an essay by Andrea Bennett. In this Walrus essay, the writer discusses the possible link between bipolar and creativity. The essay is deeply personal. “I don’t dream about not being bipolar, because I don’t know where my self ends and where the illness begins – and if there is even really a difference.”

DG

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